Transplant International ISSN 0934-0874

ORIGINAL ARTICLE

Living donor liver transplantation: effect of the type of liver graft donation on donor mortality and morbidity Lampros Kousoulas, Thomas Becker, Nicolas Richter, Nikos Emmanouilidis, Harald Schrem, Hannelore Barg-Hock, Juergen Klempnauer and Frank Lehner Department of General, Visceral and Transplant Surgery, Hanover Medical School, Hanover, Germany

Keywords donor complications, donor morbidity, donor mortality, living donor liver transplantation. Correspondence Dr. Lampros Kousoulas, Klinik fu¨r Allgemein-, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, CarlNeuberg-Str. 1, D-30625 Hannover, Germany. Tel.: +49511 5322032; fax: +49511 5324010; e-mail: kousoulas.lampros@ mh-hannover.de Received: 18 March 2010 Revision requested: 7 April 2010 Accepted: 7 October 2010 Published online: 10 November 2010 doi:10.1111/j.1432-2277.2010.01183.x

Summary To investigate the influence of the type of liver graft donation on donor mortality and morbidity. The clinical course of 87 living liver donors operated on at our center between 2002 and 2009 was retrospectively analysed and data pertaining to all complications were retrieved. No donor mortality was observed and no donor suffered any life-threatening complication. Four donors (4.6%) developed biliary leakage, nine (10.3%) had to be readmitted to hospital and six (6.9%) required some or other type of reoperation related to the previous liver donation. Reoperations included incisional or diaphragmatic hernia repair (n = 4), biliary leakage repair (n = 1) and segmental colon resection combined with diaphragmatic hernia repair (n = 1). There was a statistically significant difference in hospital stay (P < 0.001), autologous blood transfusions (P < 0.001) and operating time (P < 0.005) when right lobe donations (Segments V–VIII) were compared with left lobe (Segments II–IV) and left lateral lobe (Segments II–III) donations, whereas no difference was found between these groups regarding hospital readmission, operative revisions and the incidence or severity of complications. Right lobe donation was associated with prolonged hospital stay, increased blood transfusions and prolonged operating time when compared with left and left lateral lobe donation, whereas donor mortality and morbidity did not differ between these groups.

Introduction Living donor liver transplantation (LDLT) was developed in an attempt to increase the pool of donor organs, offering at the same time a graft in excellent condition with short ischemic time [1], reducing this way the mortality of pediatric patients on the waiting list for liver transplantation [2,3]. The first LDLT was performed in 1989, when the left lateral lobe was successfully transplanted from a mother to her son [4,5]. This success led to the adaptation of this technique all around the world and especially in Asian countries because of limited availability of cadaveric organs. The fact that the left lateral lobe of the liver does not provide sufficient liver mass to allow successful transplantation in adults led to the use of the full left or full

right liver lobe. In 1994, the first right liver LDLT was performed in a child [6], whereas the first adult-to-adult LDLT using the right lobe was performed in the same year by Fan et al. [7]. Despite the impressive results, LDLT remains one of the most complicated surgical procedures and has created controversy regarding the safety of the donor. To date, 20 deaths of living hepatic lobe donors and one donor in a chronic vegetative state of physical condition have been worldwide reported [8,9]. The most common causes of death relating to liver donation were sepsis, postoperative liver failure, myocardial infarction, cerebral hemorrhage, pulmonary embolus and complications of peptic ulcer disease [10]. Although an accurate estimation of the donor mortality risk after living liver donation is not possible, mortality approaches 0.5% for

ª 2010 The Authors Transplant International ª 2010 European Society for Organ Transplantation 24 (2011) 251–258

251

Living donor liver transplantation: donor mortality and morbidity

the right lobe donation and 0.1% for the left lobe donation [11]. Donor morbidity rates after liver graft donation range from 0% to 67%, with an overall crude complication rate of 31%, depending on the definition but also on the recognition of complications [12,13]. Among the most commonly noted postoperative complications are infections, development of incisional hernias and biliary complications [14]. The right hepatectomy is associated with higher rates of complications, especially of biliary leakage, in comparison with the left- and left lateral hepatectomy [15,16,17]. Moreover, respiratory complications including especially pulmonary embolism develop frequently mainly after right lobe hepatectomy [18,19]. Postoperative liver failure of the living donor with need for liver transplantation is a rare complication with only five cases having been reported worldwide and is associated with high donor mortality as seen from the fact that out of these five donors only one survived more than 9 months after the liver transplantation [20]. There is an extensive literature focusing on donor mortality and morbidity after living liver graft donation; Brown from New York, USA [12] reported on national data obtained from 84 different transplant centers engaged in performing LDLT. The national overall donor complication rate was estimated to be 14.5% with a rehospitalization rate of 8.5%. A donor mortality rate of 0.2% was reported. On the other hand, the overall complication rate presented by Ghobrial et al. [14] in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL) was significantly higher when compared with the numbers presented by Brown, as 38% of the living donors evaluated between 1998 and 2003 in nine transplant centers in the United States developed a postoperative complication. The majority of these complications were minor without lasting disability, but 2% of the donors developed a life-threatening complication and the overall mortality rate was 0.8%. Regarding the effect of the type of liver graft donation on donor morbidity we have to focus on the systematic review of Beavers et al. [13] who demonstrated an overall crude morbidity rate of 31% after right lobectomy, with bile leakage, prolonged ileus and minor wound problems being the most commonly noted postoperative complications. Interesting is also the latest study of Therapondos et al. [21], who presented medical outcomes of 202 donors beyond 1 year after donor hepatectomy. According to this study, almost 40% of the donors suffered a complication during the first postoperative year, but the complication rate decreased dramatically to 1.5% after the first year. There was no donor mortality in this group. The goal of this study was to investigate the influence of the type of liver graft donation on donor mortality 252

Kousoulas et al.

and morbidity. We tested whether the donation of the right hepatic lobe (Segments V–VIII) is associated with more frequent or more serious complications such as biliary leakage when compared with the donation of the left lobe (Segments II–IV) or the left lateral lobe (Segments II–III). Moreover, we investigated the influence of the different donor procedures on the necessity of intraoperative blood transfusions, the frequency of operative revisions, the need for hospital readmission, the duration of the donor operating procedure and the average hospital stay of the donors. Materials and methods From January 2002 to December 2009, 87 LDLTs were performed in the Hanover Medical School and the perioperative data of the donors were retrospectively analysed. Survival of the donors was regularly checked with the German residence registration offices, the general practitioners of the donors and our interdisciplinary outpatient clinic for liver transplant patients and living donors. Systematic follow-up of all cases was carried out until 01.02.2010. Donor demographics and the type of liver graft donation are presented in Table 1. All potential donors underwent a complete and thorough evaluation. The principal goal of the donor evaluation procedure was to determine whether the potential donor was not only medically but also psychologically suitable for living liver donation. All donors were evaluated by a hepatologist, a transplant surgeon and a psychiatrist before determining the prospective donor’s eligibility for liver donation. Donor age under 18 or over 65 years, obesity with a body mass index over 30, fatty

Table 1. Donor demographics and operative data of donor procedures. No. donors Gender (male/female) (%) Average age at time of operation (years) Donor relationship to the recipient (%) Biologically related Parent Sibling Child Not biologically related Spouse Other nonbiological Type of liver resection (%) Left lateral lobe (Segments 2 and 3) Right lobe (Segments 5, 6, 7 and 8) Left lobe (Segments 2, 3 and 4)

87 38/49 (44/56) 37 (19–60) 67 52 8 7 20 13 7

(77) (60) (9) (8) (23) (15) (8)

47 (54) 36 (41) 4 (4.6)

ª 2010 The Authors Transplant International ª 2010 European Society for Organ Transplantation 24 (2011) 251–258

Kousoulas et al.

change of the liver more than 10%, remnant liver volume